Validation of a German Body Dysmorphic Disorder Screening Scale and Clinical Interview according to ICD-11 and DSM-5 in the General Population

Validation of a German Body Dysmorphic Disorder Screening Scale and Clinical Interview according to ICD-11 and DSM-5 in the General Population | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Validation of a German Body Dysmorphic Disorder Screening Scale and Clinical Interview according to ICD-11 and DSM-5 in the General Population Johanna Sabina Schüller, Mareike Ebert, Farahnaz Tavakoli, Ulrich Stangier, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3879165/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Body dysmorphic disorder (BDD) is an impairing psychological disorder with a high prevalence in clinical and cosmetic surgery settings. In the new ICD-11, BDD is grouped with the obsessive-compulsive spectrum disorders and the diagnostic criteria are updated, largely corresponding with the DSM-5. Available diagnostic interviews and screening scales for BDD are not based on these current criteria. In this paper, a newly developed screening questionnaire (BDD-S) and structured clinical interview (BDD-CI) according to the ICD-11 and DSM-5 criteria were preliminarily validated. Methods The BDD-S and the BDD-CI cover all core BDD symptoms. Open-ended questions allow for the addition of qualitative information on affected body parts and behavioural and mental aspects. We determined the internal consistency and construct validity of the BDD-S and suggested a cutoff value. We assessed a subsample with the BDD-CI and estimated a prevalence. The BDD-S was translated into Farsi and applied to an Iranian sample. BDD-S scores, social anxiety symptoms, and general psychopathological impairment were compared between a German and an Iranian sample. Results Internal consistency of the BDD-S was excellent (ω = .92). A high correlation with the body dysmorphic concerns and moderate correlations with measures of other mental disorders supported good construct validity. We determined a cutoff value of 19 for balanced sensitivity and specificity (sensitivity = 0.92, specificity = 0.87, AUC = .94). We estimated a prevalence of 2.76% for the German sample. The cultural comparison showed that the BDD-S score was higher in the Iranian sample. Conclusions With the BDD-S, we developed an economic and versatile screening instrument based on current diagnostic criteria, to be followed up with the BDD-CI when applicable, to obtain a clinical diagnosis. In the next step, the measures must be validated in larger clinical samples. Body Dysmorphic Disorder Diagnostic Interview Screening Scale ICD-11 DSM-5 Culture Comparison Figures Figure 1 Background Body dysmorphic disorder (BDD) is characterized by an excessive preoccupation with one or more defects or flaws in one’s appearance that are not or only slightly visible to others and cause considerable suffering [ 1 ]. This may refer to one or multiple body parts, often hair, skin or facial features [ 2 ]. Individuals usually engage in ritualistic behaviours to modify or conceal the flaw, or excessively check and compare their appearance [ 3 ]. In the ICD-10, which was used from 1994 to 2022, BDD was diagnosed as hypochondriacal disorder, or, with low or missing insight, as delusional dysmorphophobia. Numerous findings over the years have provided evidence for similarities between BDD and obsessive-compulsive and related disorders (OCRD) regarding symptomatology, course of illness, comorbidity, heritability, brain function and effective treatments [e.g. 4,5–10]. Accordingly, the current conceptualizations place BDD within the OCRD in the DSM-5 [ 1 , 8 ] and the ICD-11 [ 11 , 12 ]. In both the DSM-5 and ICD-11 classification systems, repetitive behaviours are explicitly added to the definition of BDD. The presence of at least one out of (i) repetitive and excessive (checking) behaviours, (ii) attempts to alter or conceal the defect, and only in the ICD-11 (iii) avoidance of social situations or triggers is necessary for the diagnosis. The patients must show an excessive self-consciousness up to ideas of reference (not included in the DSM-5), and show significant distress or impairment in functioning. Both manuals include an insight specifier. Available Diagnostic Tools To date, BDD is still an underdiagnosed and undertreated disorder due to a lack of awareness among psychiatric and medical professionals [ 13 , 14 ]. In general psychiatric care, patients often do not express body dysmorphic concerns out of shame or lack of insight [ 13 , 15 ]. BDD patients often request cosmetic surgery. Although BDD is typically considered a contraindication for cosmetic procedures [ 16 ], surgeons often do not reliably recognize it in patients [ 17 ]. In general, missing or incorrect diagnoses prevent appropriate treatment according to guidelines. As weighted BDD prevalences are elevated for psychiatric inpatients (7.4%) and in cosmetic surgery settings (13.2%) compared to the general population (1.9%) [ 18 ], it is especially important to introduce routine screening procedures. Self-rated screening questionnaires can be used to identify potentially affected patients in various psychiatric and medical settings. However, none of the available self-rated screening scales for BDD conform to both the DSM-5 and ICD-11 criteria. In existing questionnaires, either newly added criteria are missing (e.g. behaviour rituals, self-consciousness) or only some specific examples of repetitive behaviours are asked for (e.g. BDD5-S [ 19 ] or COPS [ 20 ]). For some questionnaires, the conceptual focus deviates from the core construct of BDD, or the target population is limited (e.g. patients requesting aesthetic surgery). For individuals who have been screened positive, a thorough follow-up assessment must be carried out to confirm the diagnosis or rule out differential possibilities. The research version of the structured clinical interview for DSM-5 (SCID-5-RV) [ 21 ] assesses BDD according to DSM-5, however, no clinical interview pertaining to the current ICD-11 criteria has been published. Clinical Interview for Body Dysmorphic Disorder (BDD-CI) and Body Dysmorphic Screening Scale (BDD-S) To overcome this limitation, the working group developed a structured clinical interview BDD-CI [ 22 ] as well as an economic, self-administered questionnaire for body dysmorphic disorder BDD-S [ 23 ], which can be applied as a preliminary screening. The items of both the clinical interview and the screening scale were developed by integrating the diagnostic criteria of the DSM-5 and the ICD-11. The BDD-S is intended to identify individuals in whom clinically relevant BDD is suspected and detailed diagnostic testing is necessary. In addition, the BDD-S can provide a dimensional estimate of BDD symptomatology. The application of the BDD-S does not require any specific training and takes only five minutes, so it can be used in routine medical and psychiatric care. If the screening reveals an elevated score, the BDD-CI can be applied to obtain the formal diagnosis according to both diagnostic systems. Research Objective. The first aim of this study was to perform an initial validation of the BDD-S and test the feasibility of the BDD-CI. We report descriptive data and estimate the internal consistency of the BDD-S. Content validity can be assumed since the items were adapted from the established diagnostic criteria (DSM-5 and ICD-11) for BDD. To establish construct validity, we assess self-reported body dysmorphic concerns (DCQ), depressive symptomatology, general psychopathological impairment, and social anxiety. We expected a high correlation of the BDD-S with the Dysmorphic Concern Questionnaire (DCQ) [ 24 , 25 ]. Previous findings have shown that BDD is strongly comorbid with depression and social anxiety disorder (SAD) [ 26 – 28 ]. Therefore, we expected lower, but still substantial correlations with these measures. We determined two different cutoff values to indicate from which total score further BDD diagnostic assessment is recommended. In addition, we reported data from the application of the BDD-CI based on a subsample and estimated a prevalence. Culture Comparison BDD prevalence is estimated to be between 0.5 and 3.2 [ 18 , 29 ]. However, these estimates include only studies from Europe and the U.S., as population-level epidemiological studies have not been conducted in other cultures [ 29 ]. Three representative studies from Germany ( N = 2129, N = 2552 and N = 2510) found prevalence rates ranging from 1.7–2.9% in adults [ 9 , 30 , 31 ]. Even though the majority of related research has been conducted in the U.S. and Western countries, research on BDD in other cultures has increased in recent years. A recent meta-review compared prevalence rates of BDD symptoms between Eastern and Western countries and found no difference [ 32 ]. Due to the lack of research, however, there is still much uncertainty as to whether prevalence rates are comparable. Generally, body image dissatisfaction is on the rise in Iran [ 33 ] and the number of cosmetic procedures, especially rhinoplastic surgery, has risen strongly [ 34 , 35 ]. To date, no prevalence study of BDD has been conducted in the general population in Iran, but some subpopulations can be compared between Iran and combined samples from other countries. Prevalences seem to be higher in rhinoplastic [ 36 – 40 ], orthognathic [ 41 ] and dermatological [ 42 ] patients compared to a global sample [ 18 ]. In a student sample, the prevalence was somewhat greater in Iran [4.5%, 43] than in a combined sample of different nationalities [3.3%, 18]. However, methods for determining the diagnosis differ greatly, so all these comparisons can only be initial indications. Research Objective. It is important to establish comparability between samples from different cultural backgrounds to evaluate the extent to which findings are culturally transferable. Providing measurement tools and screening instruments in a wide range of languages will help to recognize BDD and will encourage the expansion of the research landscape outside the Western world. Therefore, the BDD-S was translated into Farsi and applied to an Iranian sample. We compared BDD-S scores between the German and the Iranian samples. Methods Participants Data from the N = 650 participants were collected as convenience samples from the general population in a German ( n = 486) and an Iranian subsample ( n = 164). In the German sample, the average age was M = 31.39 ( SD = 13.52), and 75.93% of participants were female. The German subsample that also completed the diagnostic interview ( n = 40) had a mean age of M = 31.10 ( SD = 13.51). In the all-female Iranian sample, 53.66% of participants were between 29 and 40, 31.10% were younger (18 to 28), and 17.68% were older than 40 years. A full comparison of sociodemographic data can be found in Table 1 . Table 1 Sociodemographic data of the complete sample and the subsamples Complete Sample German Sample German Interview Subsample Iranian Sample N 650 486 40 164 Age M = 31.39, (SD = 13.52) M = 31.1, (SD = 13.51) 18–28: 31.1%, 29–40: 53.66%, 41–55: 17.68% Gender Female (%) 82 75.93 60 100 No Education (%) 25.38 0.21 0 Secondary Education Completed (%) 57.69 43.42 50 14.63 Vocational Education completed (%) 43.69 24.69 17.5 University degree (%) 47.38 29.63 27.5 83.54 Doctorate degree (%) 26.77 2.06 5 7.93 In Education (%) 51.54 51.23 65 5.49 (Self-)Employed (%) 38.46 35.19 30 64.63 Other Occupation (%) 10.31 13.58 5 Measures In both samples, the BDD-S was administered in combination with another measure of BDD symptoms, depressive symptoms, general psychopathological distress, social anxiety disorder symptoms and demographic questions. From the German sample, a subsample of participants was contacted for a follow-up with the diagnostic interview BDD-CI. For the follow-up interview, we contacted participants who indicated agreement (at least 2 = “quite true”) with at least one of 4 items (Item 1: Preoccupation, Item 7: Repetitive behaviours, Item 9: Mental behaviours, or Item 12: Impairment) of the Body Dysmorphic Screening Scale and agreed to be contacted. N = 381 of our sample fulfilled these criteria, of which N = 40 were interviewed. In the German study, we used established questionnaires with good psychometric qualities. For the Iranian sample, validated questionnaire versions were used where available. Unavailable questionnaires were translated and back-translated from German to Farsi by a native speaker (FT). Body Dysmorphic Disorder Screening (BDD-S). The proposed 15-item BDD-S [ 23 ] intends to distinguish patients with BDD from healthy persons. Eight quantitative items measure concern over the imagined flaw, subjective impairment, avoidance and increased self-consciousness, as well as mental and behavioural preoccupation on a scale from 0 (“not at all true”) to 4 (“very much true”). The numerical items are summed up to calculate the total score (range 0–32). Additional items ask for the body region(s) that are the focus of preoccupation (item 2; e.g. skin, hair, face, etc.), the type of disorder-specific behaviours (item 8; e.g. checking rituals) and mental preoccupation (item 10; e.g. comparison of one’s own appearance with that of others), as well as specific life domains of impairment (item 13; e.g., couple relationship/sexuality). All qualitative items allow the selection of multiple answers and the addition of own answers, providing additional information. Item 3 is used to exclude participants whose concerns relate only to body weight and items 14 and 15 assess insight into the excessiveness of the belief. Structured Clinical Interview for Body Dysmorphic Disorder (BDD-CI). With the structured clinical interview for BDD (BDD-CI) [ 22 ], the BDD diagnosis can be obtained corresponding to ICD-11 and DSM-5 by evaluating the respective relevant criteria. The interview guideline assesses the core criteria preoccupation (item 1), self-consciousness and ideas of reference (item 2), repetitive behaviours and mental acts (item 3), avoidance (item 4) and impairment (item 5). Additional items for the insight (item 8) and muscle dysmorphia (item 7) specifiers, and eating disorder exclusion (item 6) are provided. Interview questions are supplemented by guidelines for the assessment of each criterion. Qualitative information is recorded about the body parts, the performed behaviours, and the impaired areas of life. For the ICD-11 diagnosis, the questions regarding preoccupation (Item 1), self-consciousness (Item 2) and suffering or impairment (Item 5) have to be answered positively, and either repetitive (mental) behaviours (Item 3) or avoidance (Item 4) are indicated. For the DSM-5 diagnosis, items 1, 3 and 5 have to be affirmed. For both, the exclusion of an eating disorder (Item 6) has to be considered. Dysmorphic Concern Questionnaire (DCQ). We used the German version [ 25 ] of the Dysmorphic Concern Questionnaire (DCQ) [ 24 ]. In the DCQ, participants rate dysmorphic worries on a 7-item scale with 0 = ‘not at all’, 1 = ‘like most other people’, 2 = ‘more than other people’ and 3 = ‘much more than other people’. The aggregated score ranges from 0 to 21 with higher scores representing more pronounced dysmorphic worries. A cutoff value of 14 achieved an 84.6% accuracy in classifying BDD patients [ 25 ]. A solid body of research indicates that the DCQ is a valid and reliable screening instrument [ 25 , 44 – 46 ]. A recent study confirmed a good internal consistency of \(\alpha\) = .81 and good convergent validity for a representative German sample [ 47 ]. Brief Symptom Inventory. General psychopathological distress was examined using a German version [ 48 ] of the 18-item short form of the Brief Symptom Inventory (BSI-18) [ 49 ]. The short version encompasses the three symptom areas Anxiety , Depression , and Somatization , each represented by six items that are rated on a scale from 0 (“not at all”) to 4 (“very much”). Sum scores (ranging from 0 to 24) can be calculated for each syndrome. Taken together, the three syndromes constitute the Global Severity Index (GSI, range 0–72) as a measure of general psychological distress. A representative German sample showed good internal consistency for each of the syndromes and very good internal consistency for the GSI, as well as favourable estimates of convergent validity [ 50 ]. In the Iranian sample, the 53-item version of the BSI [ 51 ] was used, for which psychometric quality is empirically supported [ 52 ]. However, in order to enable a comparison with the German sample, only the corresponding items of the BSI-18 were evaluated for the Iranian sample. Beck Depression Inventory. The German version of the BDI-Fast Screening (BDI-FS) [ 53 , 54 ], a short form of the BDI-II [ 55 ], was applied to measure depressive symptoms. For each item, one out of four statements is selected, resulting in a rating between 0 and 3. The total score ranges from 0 to 21, with higher values indicating more severe depressive symptoms. In a representative German sample, the one-factor structure and good internal consistency ( \(\alpha\) = .84) along with good convergent and satisfying discriminant validity could be supported [ 54 ]. For the Iranian sample, the BDI-V [ 56 ] was translated into Farsi. The BDI-V is a simplified version of the BDI that applies a standard Likert scale (0–5) to 20 items (sum score ranging from 0 to 100). This scale showed a good psychometric quality in a German sample [ 57 ]. Social Phobia Inventory. Symptoms of social anxiety disorder (SAD) were assessed with the Social Phobia Inventory (SPIN) [ 58 ] in the German [ 59 ] and Iranian versions [ 60 ]. In the 17-item self-report screening instrument, participants rate social anxiety, avoidance and physiological aspects of social anxiety on a Likert scale between 0 and 4 (total score ranging from 0 to 68). In the German version of the SPIN, a very high internal consistency, good retest reliability, good validity and change sensitivity were shown [ 59 ]. For the Iranian version, internal consistencies of \(\alpha\) = .66 in a clinical and \(\alpha\) = .89 in a non-clinical sample were found [ 60 ]. Data analysis Reliability of the BDD-S was assessed by estimating the internal consistency with McDonald’s \(\omega\) . To determine construct validity, correlations with another BDD measure and related constructs were calculated. We expected correlations > .70 for convergent measures, and lower values for divergent measures. We performed a ROC analysis on the German sample ( n = 486), using the DCQ score categorization based on the cutoff value of > = 14 provided by Stangier et al. [ 25 ]. A first cutoff value was determined based on maximizing the sum of sensitivity and specificity. An alternative, more sensitive cutoff value was calculated by maximization of the sensitivity. From the BDD-CI, we estimated the prevalence in the German sample. Given that the interview was not conducted in the total sample due to limited resources, the prevalence could only be estimated indirectly. We first preselected eligible participants from the total German sample with a very liberal criterion to exclude people who did not confirm any relevant item. For these N = 105 people, we assumed that the BDD diagnosis was not fulfilled. Among the N = 381 eligible participants, 40 interviews were ultimately conducted. For the 341 people who were eligible, but not interviewed for various reasons (accessibility, no consent to interview), we assumed that the prevalence was comparable to that of the sample that was interviewed. In this way, we estimated a prevalence value for the entire German sample. Results Descriptive Statistics, Reliability and Item Analysis The means, standard deviations and McDonald’s \(\omega\) values for the measured scales are given in Table 2 . Internal consistency for the BDD-S was high. All items had a discriminatory power of 0.69 or higher, except item 15, which was still within the acceptable range (discrimination 0.31). Table 2 Descriptive data of all measured constructs Complete Sample German Sample Iranian Sample \(\omega\) M SD M SD M SD BDD Screening 0.92 13.39 8.12 12.72 7.96 15.88 8.25 BSI-GSI (18) 0.93 14.37 12.72 12.64 11.67 19.91 14.30 SPIN 0.95 14.61 12.97 15.65 13.41 11.28 10.84 DCQ 0.87 / / 6.55 4.24 / / BDI-FS 0.91 / / 3.88 3.82 / / BDI-V 0.94 / / / / 28.29 20.27 Note. Complete sample: n = 650, German sample: n = 486, Iranian sample: n = 164. McDonald \(\omega\) is calculated for the complete sample where possible, or for the respective subsample that completed each measure. Validity As expected, we found high correlations (> .70) with BDD symptom severity assessed by the DCQ and medium to large correlations with depression, general psychopathology and SAD symptoms for the German sample. In the Iranian sample, however, correlations of the BDD-S with the BDI, BSI and SPIN were considerably lower (Table 3 ). Table 3 Correlations of the BDD Screening with other measured constructs Complete Sample German Sample Iran Sample r p r p r p Expected high correlation DCQ / / 0.76 < .001 / / Expected medium correlation BDI 0.32 < .001 0.57 < .001 0.29 .001 BSI-GSI (18) 0.46 < .001 0.52 < .001 0.20 .024 SPIN 0.49 < .001 0.56 < .001 0.33 < .001 Note. DCQ: Dysmorphic Concerns Questionnaire, BDI: Beck Depression Inventory, BSI-GSI: Brief Symptom Inventory Global Severity Index, 18-item version, SPIN: Social Phobia Inventory. In the German sample, the BDI-FS was used. In the Iranian sample, the BDI-V was used. Cutoff Value The cutoff based on maximizing the sum of sensitivity and specificity was 19. This cutoff value reached a sensitivity of 0.92 and a specificity of 0.87. The area under the curve was 0.94. N = 110 (22.63%) of the German sample and N = 41 (25.00%) of the Iranian sample reached this value. An alternative cutoff point that maximizes sensitivity was 14. This cutoff value reached a sensitivity of 1.00 and a specificity of 0.64. The area under the curve was 0.94. This cutoff value was reached by N = 199 (40.95%) of the German sample and N = 70 (42.68%) of the Iranian sample. Prevalence Based on the ICD-11 criteria, four people (10.00%) fulfilled the diagnosis of BDD. Using the DSM-5 criteria, instead, five participants (12.50%) from the assessed sample fulfilled the diagnostic criteria for BDD. Among the diagnosed participants, one showed good to fair insight (two for DSM-5), and for three participants, insight was rated poor. Based on the ICD-11 criteria we estimated a prevalence of 2.76% for the whole sample. The N = 105 participants who did not fulfil our interview eligibility criteria showed a mean BDD-S value of M = 4.33. The mean score of the interviewed patients was M = 14.85 ( SD = 7.80), which was not significantly different to that of the eligible patients who were not interviewed ( M = 15.05, SD = 7.24, t = 0.15, p = .878). Cultural Comparison The BDD-S total score of the German ( M = 12.72, SD = 7.96) and the Iranian sample ( M = 15.88, SD = 8.25) differed significantly ( t = -3.92, p = < .001) (Fig. 1 ). Considering that the Iranian sample included only female participants, we also examined gender differences for the BDD-S score. In the German sample, the difference between female ( M = 13.49, SD = 7.95) and male participants M = 10.09 SD = 7.30) was significant ( t = 4.26, p = < .001). Comparing only female participants from the German and Iranian samples, the difference in BDD-S scores remained significant, however ( t = -2.88, p = .004). The BSI value was greater in the Iranian sample ( M = 19.91, SD = 14.30) than in the German sample ( M = 12.64, SD = 11.67 t = -5.67, p = < .001). However, SAD symptoms were significantly greater in the German sample ( M = 15.65, SD = 13.41) than in the Iranian sample ( M = 11.28, SD = 10.84, t = 4.04, p = < .001). Discussion In this study, we presented a new screening questionnaire (BDD-S) and a structured clinical interview guide (BDD-CI) for body dysmorphic disorder that incorporate the current diagnostic criteria from both the DSM-5 and the ICD-11. Content validity, as secured by up-to-date criteria, is crucial as the absence of important components or a diverging construct focus can lead to both under- and overrecognition. If BDD is not recognized, or misdiagnosed e.g. as mood disorder, the resulting inappropriate treatment, or lack thereof, leads to persisting psychopathology. Underrecognition also poses the risk of performing cosmetic surgery which is usually ineffective at reducing distress for BDD patients [ 61 , 62 ]. Mitigating the underrecognition of BDD in the German psychiatric and medical care landscape will help to ensure that patients receive appropriate treatment according to relevant clinical guidelines. Screenings that lack recently added criteria (e.g. repetitive behaviours or avoidance) might instead cause overrecognition, causing a waste of resources, as performing diagnostic procedures is time-consuming. In a large representative German sample, the addition of the criterion of ritualistic behaviours did not lead to a difference in caseness determined by a clinical interview [ 9 ]. However, this would likely be different in self-report questionnaires. Appearance-related concerns are common in the population [ 63 ], and it is difficult for affected persons to assess whether their preoccupation with a flaw is clinically significant. Therefore, in self-report questionnaires, the inclusion of the more objective behaviour criterion is much more important for specificity. A lack of content validity can also cause difficulties in distinguishing common differential diagnoses, such as eating disorders. Accordingly, by providing a screening instrument with good content validity, the present investigation is an important contribution to the appropriate care of this patient population. Despite its relative prevalence in psychiatric and cosmetic surgery settings [ 15 , 18 ], medical staff and surgeons often lack knowledge about BDD [ 16 , 17 ]. As patients usually do not report appearance-related concerns spontaneously out of shame or lack of insight [ 13 , 15 ], it is important to screen for BDD in routine assessments. Due to its quick and easy application, the BDD-S is a practical and useful tool intended to screen for BDD in all psychiatric, psychotherapeutic and medical settings. With the query of the relevant body parts and the existing control behaviours, individual qualitative information for therapy planning is also recorded here in a very economical way. The total BDD-S score can be interpreted as a dimensional estimate of symptom severity and can be used for monitoring therapy success. When an elevated BDD-S score indicates the need for further diagnostics, the BDD-CI can be used as a follow-up by trained professionals to obtain the BDD diagnosis. It enables the determination of a valid diagnosis according to ICD-11 and DSM-5, by evaluating the appropriate criteria. The screening questionnaire was translated into Farsi, as the dissemination of adequate and validated measurement instruments is lacking, and the rapidly increasing field of research can benefit from this. Psychometric quality of the BDD-S We found an excellent internal consistency of the BDD-S. Content validity is assured because the items were derived from the diagnostic criteria in the ICD-11 and the DSM-5. As shown by the high correlation with the DCQ, the construct validity of the BDD-S is good. The moderate to high correlations with other psychopathological constructs reflect the expected relationship to comorbid disorders and psychopathological burden [ 64 , 65 ]. We suggested two different cutoff values that prioritize different criteria. The choice of the appropriate cutoff value may vary depending on the setting. The recommended value for general screening in a low-risk population or routine mental health care is 19. This value balances a high sensitivity of 0.92 and specificity 0.87, to combine a good recognition with time efficiency. As cosmetic surgery-seeking patients show a high prevalence of BDD [ 17 , 18 ], the more sensitive cutoff value (14) might be appropriate here, as well as in specific clinical settings and other high-risk populations. Prevalence Estimate The prevalence in the German sample was estimated to be 2.76%, applying the ICD-11 criteria. This value is in line with previous findings, which estimated the prevalence in German adults between 1.7% and 2.9% [ 9 , 30 , 31 ], and somewhat higher than the weighted estimate (1.9%) from a cross-national study [ 18 ]. However, it is important to note here that our prevalence estimate is based only on a subsample ( N = 40), from which the value was extrapolated to the entire sample. Possible biases in the selection of samples and thereby limited generalizability cause uncertainty and the estimate should therefore be interpreted with caution. If the criteria according to DSM-5 are evaluated, a slightly higher number of cases is obtained. The ICD-11 criteria allow for avoidance to be the only behavioural consequence of the appearance preoccupation but require self-consciousness or ideas of reference to be present. This might explain the difference in caseness in our sample. Culture Comparison We found a higher total BDD-S score for the Iranian sample. This is consistent with the fact that comparatively high prevalences were found in cosmetic surgery settings [ 36 – 42 ] and student samples [ 43 ] in Iran, compared to global studies from the same subpopulations [ 18 ]. However, there are no direct comparison studies between Germany and Iran that can be used as a reference. Notably, the BSI values are significantly greater in the Iranian sample, as well, while SAD symptom severity is greater in the German sample. Due to the different BDI questionnaire versions used, it is not possible to compare the depression values of the two samples, which is a limitation of our study. Overall, our findings support earlier research showing that BDD might be more prevalent in the Iranian population, in connection with high psychopathological distress (BSI). However, selection effects may be involved and must be taken into account as possible alternative explanation for the higher BDD-S values. Strength and Limitations, Future Studies A strength of this study was the size of the complete sample ( N = 650). Since the smaller Iranian sample consisted only of women, results can of course only be generalized to the female population. As only part of the German sample ( N = 40) completed the interview, the prevalence stated is only a preliminary estimate and must be checked on further samples. The study was conducted using convenience samples from the general population, therefore an important limitation is the lack of clinical data. The next step is therefore the validation of the screening scale and the clinical interview in patient populations. Future studies with clinical and healthy populations should reassess the proposed cutoff values, and provide more data to evaluate the construct validity. Conclusions To summarize, in this article we preliminarily validated a new screening instrument and clinical interview for BDD. These are the first measurement instruments to reflect the currently valid criteria from both ICD-11 and DSM-5. It is of great value to provide questionnaires that assess BDD according to the current criteria, as many older screening questionnaires have a different focus in terms of content, which can lead to over- or underrecognition. The proposed instruments therefore contribute to the correct identification of patients with BDD and thus to improved psychiatric and medical care. Abbreviations • AUC • Area Under the Curve • BDD • Body Dysmorphic Disorder • BDD-CI • Clinical Interview for Body Dysmorphic Disorder • BDD-S • Body Dysmorphic Disorder Screening Scale • BDD5-S • Body Dysmorphic Disorder Screener for DSM-5 • BDI • Becks Depression Inventory • BSI • Brief Symptom Inventory • COPS • Cosmetic Procedure Screening Questionnaire • DCQ • Dysmorphic Concerns Questionnaire • DSM • Diagnostic and Statistical Manual of Mental Disorders • GSI • Global Severity Index • ICD • International Statistical Classification of Diseases and Related Health Problems • OCRD • Obsessive-Compulsive and Related Disorders • SAD • Social Anxiety Disorder • SCID-5-RV • Structured Clinical Interview for DSM-5, Research Version • SPIN • Social Phobia Inventory Declarations Ethics approval and consent to participate The ethics committee of the Department of Psychology and Sports Science at the Goethe University Frankfurt approved the procedures (Reference number 2021-04). Participants provided informed consent to all study procedures. Consent for publication Not applicable Availability of data and materials As the data sets analysed in the current study are clinical data they are not made publicly available. Competing interests The authors declare that they have no competing interests. Funding No funding was used for this project outside of university funds. Authors’ contributions JS was involved in the conceptualization of the study design, administered the project, collected data for the German sample, curated, analyzed and interpreted the data, and created the first draft of the manuscript. ME collected data for the German sample, contributed to the formal analysis and with the first draft of the manuscript. FT collected data for the Iranian sample and reviewed the manuscript. VR was involved in the conceptualization of the study design, and administration of the project, provided supervision and reviewed and edited the manuscript. US was involved in the conceptualization of the study design and administration of the project, provided supervision and reviewed and edited the manuscript. All authors read and approved the final manuscript. Acknowledgements We would like to thank Anna Chlup and Sophia Jacqueline Pieronczyk for their support in conducting the interviews. References APA. Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition. Washington, DC: American Psychiatric Association Press. ; 2013. https://doi.org/10.1176/appi.books.9780890425596 . Veale D, Boocock A, Gournay K, Dryden W, Shah F, Willson R, et al. Body dysmorphic disorder. A survey of fifty cases. Br J Psychiatry: J Mental Sci. 1996;169:196–201. https://doi.org/10.1192/bjp.169.2.196 . Phillips KA, Menard W, Fay C. Gender similarities and differences in 200 individuals with body dysmorphic disorder. Compr Psychiatr. 2006;47:77–87. https://doi.org/10.1016/j.comppsych.2005.07.002 . 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Prevalence of Body Dysmorphic Disorder and Surgeon Diagnostic Accuracy in Facial Plastic and Oculoplastic Surgery Clinics. JAMA Facial Plast Surg. 2017;19:269–74. https://doi.org/10.1001/jamafacial.2016.1535 . Veale D, Gledhill LJ, Christodoulou P, Hodsoll J. Body dysmorphic disorder in different settings: A systematic review and estimated weighted prevalence. Body Image. 2016;18:168–86. https://doi.org/10.1016/j.bodyim.2016.07.003 . Van Rood YR, Wyk van N, Böhringer S, van der Wee NJA, Möllmann A, Dingemans AE. Development of a body dysmorphic disorder screener for DSM-5 (BDDS-5). Compr Psychiatr. 2023;127:152416. https://doi.org/10.1016/j.comppsych.2023.152416 . Veale D, Ellison N, Werner TG, Dodhia R, Serfaty MA, Clarke A. Development of a Cosmetic Procedure Screening Questionnaire (COPS) for Body Dysmorphic Disorder. J Plast Reconstr Aesthetic Surg. 2012;65:530–2. https://doi.org/10.1016/j.bjps.2011.09.007 . First MB, Williams JBW, Karg RS, Spitzer RL. 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Associations in the longitudinal course of body dysmorphic disorder with major depression, obsessive–compulsive disorder, and social phobia. J Psychiatr Res. 2006;40:360–9. https://doi.org/10.1016/j.jpsychires.2005.10.001 . Phillips KA, Didie ER, Menard W. Clinical features and correlates of major depressive disorder in individuals with body dysmorphic disorder. J Affect Disord. 2007;97:129–35. https://doi.org/10.1016/j.jad.2006.06.006 . Minty A, Minty G. The prevalence of body dysmorphic disorder in the community: A systematic review. Glob PSYCHIATRY Arch. 2021;4:130–54. https://doi.org/10.52095/gp.2021.8113 . Rief W, Buhlmann U, Wilhelm S, Borkenhagen A, Brähler E. The prevalence of body dysmorphic disorder: A population-based survey. Psychol Med. 2006;36:877–85. https://doi.org/10.1017/S0033291706007264 . Buhlmann U, Glaesmer H, Mewes R, Fama JM, Wilhelm S, Brähler E, et al. Updates on the prevalence of body dysmorphic disorder: A population-based survey. Psychiatry Res. 2010;178:171–5. https://doi.org/10.1016/j.psychres.2009.05.002 . Mascarenhas JG, de Deus MM, de Kosugi EM. Guimarães V. Prevalence of Body Dysmorphic Disorder and Dysmorphic Symptoms in Rhinoplasty Candidates: A Systematic Review and Meta-Analysis. Trends in Psychology. 2022. https://doi.org/10.1007/s43076-022-00237-9 . Garrusi B, Baneshi MR. Body dissatisfaction among Iranian youth and adults. Cadernos de saúde pública. 2017;33. https://doi.org/10.1590/0102-311x00024516 . Bidkhori M, Yaseri M, Akbari Sari A, Majdzadeh R. Relationship between Socioeconomic Factors and Incidence of Cosmetic Surgery in Tehran, Iran. Iran J Public Health. 2021;50:360–8. https://doi.org/10.18502/ijph.v50i2.5351 . Borujeni LA, Pourmotabed S, Abdoli Z, Ghaderi H, Mahmoodnia L, Sedehi M, et al. A Comparative Analysis of Patients’ Quality of Life, Body Image and Self-confidence Before and After Aesthetic Rhinoplasty Surgery. Aesth Plast Surg. 2020;44:483–90. https://doi.org/10.1007/s00266-019-01559-3 . Alavi M, Kalafi Y, Dehbozorgi GR, Javadpour A. Body dysmorphic disorder and other psychiatric morbidity in aesthetic rhinoplasty candidates. J Plast Reconstr Aesthetic Surg. 2011;64:738–41. https://doi.org/10.1016/j.bjps.2010.09.019 . Ghadakzadeh S, Ghazipour A, Khajeddin N, Karimian N, Borhani M. Body Image Concern Inventory (BICI) for Identifying Patients with BDD Seeking Rhinoplasty: Using a Persian (Farsi) Version. Aesthetic Plast Surg. 2011;35:989–94. https://doi.org/10.1007/s00266-011-9718-8 . Fathololoomi MR, Goljanian TA, Fattahi BA, Noohi SA, Makhdoom A. Body dysmorphic disorder in aesthetic rhinoplasty candidates. Pak J Med Sci. 2013;29:197–200. https://doi.org/10.12669/pjms.291.2733 . Jahandideh H, Dehghani Firouzabadi F, Dehghani Firouzabadi M, Ashouri A, Haghighi A, Roomiani M. Persian Validation and Cultural Adaptation of the Body Dysmorphic Disorder Questionnaire-Aesthetic Surgery for Iranian Rhinoplasty Patients. World J Plast Surg. 2021;10:55–60. Hassanpour M, Ya’ghoubi A, Faramarzi M. Levels of Body Dysmorphic Disorder (BDD) Incidence in Individuals Seeking Rhino Plastic Surgery. World Appl Sci J. 2014;30:1259–63. Alizadeh FL, Dehghani L, Zarei M. Investigating the Prevalence of Body Dysmorphic Disorder BDD) in Orthosurgery Patients. Iran J Orthod. 2023. https://doi.org/10.22034/ijo.2023.1983270.1099 . Ehsani A, Fakour Y, Gholamali F, Mokhtari L, Hosseini MS, Khosrovanmehr N, et al. Prevalence of body dysmorphic disorder in patients referred to Razi hospital cosmetic clinic with complaints of cosmetic disorders. Tehran-Univ-Med-J. 2013;71:164–70. Aflakseir A, Jamali S, Mollazadeh J. Prevalence of Body Dysmorphic Disorder Among a Group of College Students in Shiraz. Zahedan J Res Med Sci 2021;23. https://doi.org/10.5812/zjrms.95247 . Jorgensen L, Castle DJ, Roberts C, Groth-Marnat G, Australian. New Z J Psychiatry. 2001;35:124–8. https://doi.org/10.1046/j.1440-1614.2001.00860.x . Mancuso SG, Knoesen NP, Castle DJ. The Dysmorphic Concern Questionnaire: A screening measure for body dysmorphic disorder. Aust N Z J Psychiatry 2010:100416054850067–8. https://doi.org/10.3109/00048671003596055 . Senín-Calder’on C, Vald’es-Díaz M, Benítez-Hern’andez MM, N’uñez-Gait’an MC, Perona-Garcel’an S, Martínez-Cervantes R et al. Validation of Spanish Language Evaluation Instruments for Body Dysmorphic Disorder and the Dysmorphic Concern Construct. Frontiers in Psychology. 2017;8:1107. https://doi.org/10.3389/fpsyg.2017.01107 . Schieber K, Kollei I, de Zwaan M, Martin A. The Dysmorphic Concern Questionnaire in the German General Population: Psychometric Properties and Normative Data. Aesthetic Plast Surg. 2018;42:1412–20. https://doi.org/10.1007/s00266-018-1183-1 . Spitzer C, Hammer S, Löwe B, Grabe H, Barnow S, Rose M, et al. Die Kurzform des Brief Symptom Inventory (BSI – 18): erste Befunde zu den psychometrischen Kennwerten der deutschen Version. Fortschr Der Neurologie \cdot Psychiatrie. 2011;79:517–23. https://doi.org/10.1055/s-0031-1281602 . Derogatis LR. BSI 18, Brief Symptom Inventory 18: Administration, scoring, and procedures manual. Minneapolis, MN, USA: NCS Pearson; 2000. Franke GH, Jaeger S, Glaesmer H, Barkmann C, Petrowski K, Braehler E. Psychometric analysis of the brief symptom inventory 18 (BSI-18) in a representative German sample. BMC Med Res Methodol. 2017;17:14. https://doi.org/10.1186/s12874-016-0283-3 . Derogatis LR, Spencer PM. The Brief Symptom Inventory (BSI) administration, scoring & procedures manual-I. John Hopkins University School of Medicine; 1982. Mohammadkhani P, Dobson KS, Amiri M, Ghafari FH. Psychometric properties of the Brief Symptom Inventory in a sample of recovered Iranian depressed patients. Int J Clin Health Psychol. 2010;10:541–51. Beck AT, Steer RA, Brown GK. BDI-Fast Screen for medical patients: Manual. San Antonio: The Psychological Corporation; 2000. Kliem S, Mößle T, Zenger M, Brähler E. Reliability and validity of the Beck Depression Inventory-Fast Screen for medical patients in the general German population. J Affect Disord. 2014;156:236–9. https://doi.org/10.1016/j.jad.2013.11.024 . Hautzinger M, Keller F, Kühner C. Beck Depressions-Inventar (BDI-II). Frankfurt Am Main: Harcourt Test Services GmbH; 2006. Schmitt M, Maes J. Vorschlag zur Vereinfachung des Beck-Depressions-Inventars (BDI). Diagnostica. 2000;46:38–46. Schmitt M, Beckmann M, Dusi D, Maes J, Schiller A, Schonauer K. Messgüte des vereinfachten Beck-Depressions-Inventars (BDI-V). Diagnostica. 2003;49:147–56. Mattick RP, Clarke JC. Development and validation of measures of social phobia scrutiny fear and social interaction anxiety. Behav Res Ther. 1998;36:455–70. https://doi.org/10.1016/S0005-7967(97)10031-6 . von Consbruch K, Stangier U, Heidenreich T, Hogrefe Verlag. SOZAS Skalen zur Sozialen Angststörung: Soziale-Phobie-Inventar (SPIN), Soziale-Interaktions-Angst-Skala (SIAS), Soziale-Phobie-Skala (SPS), Liebowitz-Soziale-Angst-Skala (LSAS). 1. Auflage. Göttingen: Hogrefe; 2016. Dogaheh ER, Psychometric Properties of Farsi Version of the Social Phobia Inventory (SPIN). Procedia - Social and Behavioral Sciences. 2013;84:763–8. https://doi.org/10.1016/j.sbspro.2013.06.642 . Crerand CE, Menard W, Phillips KA. Surgical and Minimally Invasive Cosmetic Procedures among Persons with Body Dysmorphic Disorder. Ann Plast Surg. 2010;65:11–6. https://doi.org/10.1097/SAP.0b013e3181bba08f . Bowyer L, Krebs G, Mataix-Cols D, Veale D, Monzani B. A critical review of cosmetic treatment outcomes in body dysmorphic disorder. Body Image. 2016;19:1–8. https://doi.org/10.1016/j.bodyim.2016.07.001 . Harris DL, Carr AT. Prevalence of concern about physical appearance in the general population. Br J Plast Surg. 2001;54:223–6. https://doi.org/10.1054/bjps.2001.3550 . Gunstad J, Phillips KA. Axis I comorbidity in body dysmorphic disorder. Compr Psychiatr. 2003;44:270–6. https://doi.org/10.1016/S0010-440X(03)00088-9 . Hartmann AS, Staufenbiel T, Bielefeld L, Buhlmann U, Heinrichs N, Martin A, et al. An empirically derived recommendation for the classification of body dysmorphic disorder: Findings from structural equation modeling. PLoS ONE. 2020;15:e0233153. https://doi.org/10.1371/journal.pone.0233153 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3879165","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":268870208,"identity":"8249122a-8105-4d5b-b98e-294f8d7ef3d1","order_by":0,"name":"Johanna Sabina Schüller","email":"data:image/png;base64,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","orcid":"","institution":"Goethe University Frankfurt","correspondingAuthor":true,"prefix":"","firstName":"Johanna","middleName":"Sabina","lastName":"Schüller","suffix":""},{"id":268870209,"identity":"a70de90e-2a8a-4163-a0fa-82859b484248","order_by":1,"name":"Mareike Ebert","email":"","orcid":"","institution":"Goethe University Frankfurt","correspondingAuthor":false,"prefix":"","firstName":"Mareike","middleName":"","lastName":"Ebert","suffix":""},{"id":268870210,"identity":"20d42e06-2c08-4f75-86b0-13b726e73c4a","order_by":2,"name":"Farahnaz Tavakoli","email":"","orcid":"","institution":"Goethe University Frankfurt","correspondingAuthor":false,"prefix":"","firstName":"Farahnaz","middleName":"","lastName":"Tavakoli","suffix":""},{"id":268870211,"identity":"bcbb5376-a2ea-4766-9970-6898393a9f86","order_by":3,"name":"Ulrich Stangier","email":"","orcid":"","institution":"Goethe University Frankfurt","correspondingAuthor":false,"prefix":"","firstName":"Ulrich","middleName":"","lastName":"Stangier","suffix":""},{"id":268870212,"identity":"766dc4f1-b1a1-425a-a899-064f484d6e2e","order_by":4,"name":"Viktoria Ritter","email":"","orcid":"","institution":"Goethe University Frankfurt","correspondingAuthor":false,"prefix":"","firstName":"Viktoria","middleName":"","lastName":"Ritter","suffix":""}],"badges":[],"createdAt":"2024-01-19 15:44:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3879165/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3879165/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":50121468,"identity":"df994478-e1ce-4bcf-a31f-06612f480a62","added_by":"auto","created_at":"2024-01-24 19:46:29","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":2337,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of BDD-S Score between a German and an Iranian sample\u003c/p\u003e","description":"","filename":"Figure147.png","url":"https://assets-eu.researchsquare.com/files/rs-3879165/v1/e7cb154b6ed73c8a63c88064.png"},{"id":59828799,"identity":"c1562a9b-b302-4f2a-9e9e-19ac946a44ff","added_by":"auto","created_at":"2024-07-08 06:53:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":620072,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3879165/v1/90768497-839d-4751-864f-755c95755c7e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Validation of a German Body Dysmorphic Disorder Screening Scale and Clinical Interview according to ICD-11 and DSM-5 in the General Population","fulltext":[{"header":"Background","content":"\u003cp\u003eBody dysmorphic disorder (BDD) is characterized by an excessive preoccupation with one or more defects or flaws in one\u0026rsquo;s appearance that are not or only slightly visible to others and cause considerable suffering [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. This may refer to one or multiple body parts, often hair, skin or facial features [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Individuals usually engage in ritualistic behaviours to modify or conceal the flaw, or excessively check and compare their appearance [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In the ICD-10, which was used from 1994 to 2022, BDD was diagnosed as hypochondriacal disorder, or, with low or missing insight, as delusional dysmorphophobia. Numerous findings over the years have provided evidence for similarities between BDD and obsessive-compulsive and related disorders (OCRD) regarding symptomatology, course of illness, comorbidity, heritability, brain function and effective treatments [e.g. 4,5\u0026ndash;10]. Accordingly, the current conceptualizations place BDD within the OCRD in the DSM-5 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] and the ICD-11 [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In both the DSM-5 and ICD-11 classification systems, repetitive behaviours are explicitly added to the definition of BDD. The presence of at least one out of (i) repetitive and excessive (checking) behaviours, (ii) attempts to alter or conceal the defect, and only in the ICD-11 (iii) avoidance of social situations or triggers is necessary for the diagnosis. The patients must show an excessive self-consciousness up to ideas of reference (not included in the DSM-5), and show significant distress or impairment in functioning. Both manuals include an insight specifier.\u003c/p\u003e \u003cp\u003eAvailable Diagnostic Tools\u003c/p\u003e \u003cp\u003eTo date, BDD is still an underdiagnosed and undertreated disorder due to a lack of awareness among psychiatric and medical professionals [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In general psychiatric care, patients often do not express body dysmorphic concerns out of shame or lack of insight [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. BDD patients often request cosmetic surgery. Although BDD is typically considered a contraindication for cosmetic procedures [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], surgeons often do not reliably recognize it in patients [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In general, missing or incorrect diagnoses prevent appropriate treatment according to guidelines. As weighted BDD prevalences are elevated for psychiatric inpatients (7.4%) and in cosmetic surgery settings (13.2%) compared to the general population (1.9%) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], it is especially important to introduce routine screening procedures. Self-rated screening questionnaires can be used to identify potentially affected patients in various psychiatric and medical settings. However, none of the available self-rated screening scales for BDD conform to both the DSM-5 and ICD-11 criteria. In existing questionnaires, either newly added criteria are missing (e.g. behaviour rituals, self-consciousness) or only some specific examples of repetitive behaviours are asked for (e.g. BDD5-S [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] or COPS [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]). For some questionnaires, the conceptual focus deviates from the core construct of BDD, or the target population is limited (e.g. patients requesting aesthetic surgery). For individuals who have been screened positive, a thorough follow-up assessment must be carried out to confirm the diagnosis or rule out differential possibilities. The research version of the structured clinical interview for DSM-5 (SCID-5-RV) [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] assesses BDD according to DSM-5, however, no clinical interview pertaining to the current ICD-11 criteria has been published.\u003c/p\u003e \u003cp\u003eClinical Interview for Body Dysmorphic Disorder (BDD-CI) and Body Dysmorphic Screening Scale (BDD-S)\u003c/p\u003e \u003cp\u003eTo overcome this limitation, the working group developed a structured clinical interview BDD-CI [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] as well as an economic, self-administered questionnaire for body dysmorphic disorder BDD-S [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], which can be applied as a preliminary screening. The items of both the clinical interview and the screening scale were developed by integrating the diagnostic criteria of the DSM-5 and the ICD-11. The BDD-S is intended to identify individuals in whom clinically relevant BDD is suspected and detailed diagnostic testing is necessary. In addition, the BDD-S can provide a dimensional estimate of BDD symptomatology. The application of the BDD-S does not require any specific training and takes only five minutes, so it can be used in routine medical and psychiatric care. If the screening reveals an elevated score, the BDD-CI can be applied to obtain the formal diagnosis according to both diagnostic systems.\u003c/p\u003e \u003cp\u003eResearch Objective.\u003c/p\u003e \u003cp\u003eThe first aim of this study was to perform an initial validation of the BDD-S and test the feasibility of the BDD-CI. We report descriptive data and estimate the internal consistency of the BDD-S. Content validity can be assumed since the items were adapted from the established diagnostic criteria (DSM-5 and ICD-11) for BDD. To establish construct validity, we assess self-reported body dysmorphic concerns (DCQ), depressive symptomatology, general psychopathological impairment, and social anxiety. We expected a high correlation of the BDD-S with the Dysmorphic Concern Questionnaire (DCQ) [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Previous findings have shown that BDD is strongly comorbid with depression and social anxiety disorder (SAD) [\u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Therefore, we expected lower, but still substantial correlations with these measures. We determined two different cutoff values to indicate from which total score further BDD diagnostic assessment is recommended. In addition, we reported data from the application of the BDD-CI based on a subsample and estimated a prevalence.\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eCulture Comparison\u003c/h2\u003e \u003cp\u003eBDD prevalence is estimated to be between 0.5 and 3.2 [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. However, these estimates include only studies from Europe and the U.S., as population-level epidemiological studies have not been conducted in other cultures [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Three representative studies from Germany (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2129, \u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2552 and \u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2510) found prevalence rates ranging from 1.7\u0026ndash;2.9% in adults [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Even though the majority of related research has been conducted in the U.S. and Western countries, research on BDD in other cultures has increased in recent years. A recent meta-review compared prevalence rates of BDD symptoms between Eastern and Western countries and found no difference [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Due to the lack of research, however, there is still much uncertainty as to whether prevalence rates are comparable. Generally, body image dissatisfaction is on the rise in Iran [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] and the number of cosmetic procedures, especially rhinoplastic surgery, has risen strongly [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. To date, no prevalence study of BDD has been conducted in the general population in Iran, but some subpopulations can be compared between Iran and combined samples from other countries. Prevalences seem to be higher in rhinoplastic [\u003cspan additionalcitationids=\"CR37 CR38 CR39\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], orthognathic [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e] and dermatological [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e] patients compared to a global sample [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In a student sample, the prevalence was somewhat greater in Iran [4.5%, 43] than in a combined sample of different nationalities [3.3%, 18]. However, methods for determining the diagnosis differ greatly, so all these comparisons can only be initial indications.\u003c/p\u003e \u003cp\u003eResearch Objective.\u003c/p\u003e \u003cp\u003eIt is important to establish comparability between samples from different cultural backgrounds to evaluate the extent to which findings are culturally transferable. Providing measurement tools and screening instruments in a wide range of languages will help to recognize BDD and will encourage the expansion of the research landscape outside the Western world. Therefore, the BDD-S was translated into Farsi and applied to an Iranian sample. We compared BDD-S scores between the German and the Iranian samples.\u003c/p\u003e \u003c/div\u003e"},{"header":"Methods","content":"\u003cp\u003eParticipants\u003c/p\u003e \u003cp\u003eData from the \u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;650 participants were collected as convenience samples from the general population in a German (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;486) and an Iranian subsample (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;164). In the German sample, the average age was \u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;31.39 (\u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;13.52), and 75.93% of participants were female. The German subsample that also completed the diagnostic interview (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;40) had a mean age of \u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;31.10 (\u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;13.51). In the all-female Iranian sample, 53.66% of participants were between 29 and 40, 31.10% were younger (18 to 28), and 17.68% were older than 40 years. A full comparison of sociodemographic data can be found in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic data of the complete sample and the subsamples\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComplete Sample\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGerman Sample\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGerman Interview Subsample\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIranian Sample\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e650\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e486\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e164\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;31.39, (SD\u0026thinsp;=\u0026thinsp;13.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u0026thinsp;=\u0026thinsp;31.1, (SD\u0026thinsp;=\u0026thinsp;13.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18\u0026ndash;28: 31.1%, \u003c/p\u003e \u003cp\u003e29\u0026ndash;40: 53.66%, 41\u0026ndash;55: 17.68%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender Female (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo Education (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary Education Completed (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14.63\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVocational Education completed (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUniversity degree (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e83.54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoctorate degree (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.93\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn Education (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(Self-)Employed (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e64.63\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther Occupation (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMeasures\u003c/p\u003e \u003cp\u003eIn both samples, the BDD-S was administered in combination with another measure of BDD symptoms, depressive symptoms, general psychopathological distress, social anxiety disorder symptoms and demographic questions. From the German sample, a subsample of participants was contacted for a follow-up with the diagnostic interview BDD-CI. For the follow-up interview, we contacted participants who indicated agreement (at least 2 = \u0026ldquo;quite true\u0026rdquo;) with at least one of 4 items (Item 1: Preoccupation, Item 7: Repetitive behaviours, Item 9: Mental behaviours, or Item 12: Impairment) of the Body Dysmorphic Screening Scale and agreed to be contacted. \u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;381 of our sample fulfilled these criteria, of which \u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;40 were interviewed. In the German study, we used established questionnaires with good psychometric qualities. For the Iranian sample, validated questionnaire versions were used where available. Unavailable questionnaires were translated and back-translated from German to Farsi by a native speaker (FT).\u003c/p\u003e \u003cp\u003eBody Dysmorphic Disorder Screening (BDD-S).\u003c/p\u003e \u003cp\u003eThe proposed 15-item BDD-S [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] intends to distinguish patients with BDD from healthy persons. Eight quantitative items measure concern over the imagined flaw, subjective impairment, avoidance and increased self-consciousness, as well as mental and behavioural preoccupation on a scale from 0 (\u0026ldquo;not at all true\u0026rdquo;) to 4 (\u0026ldquo;very much true\u0026rdquo;). The numerical items are summed up to calculate the total score (range 0\u0026ndash;32). Additional items ask for the body region(s) that are the focus of preoccupation (item 2; e.g. skin, hair, face, etc.), the type of disorder-specific behaviours (item 8; e.g. checking rituals) and mental preoccupation (item 10; e.g. comparison of one\u0026rsquo;s own appearance with that of others), as well as specific life domains of impairment (item 13; e.g., couple relationship/sexuality). All qualitative items allow the selection of multiple answers and the addition of own answers, providing additional information. Item 3 is used to exclude participants whose concerns relate only to body weight and items 14 and 15 assess insight into the excessiveness of the belief.\u003c/p\u003e \u003cp\u003eStructured Clinical Interview for Body Dysmorphic Disorder (BDD-CI).\u003c/p\u003e \u003cp\u003eWith the structured clinical interview for BDD (BDD-CI) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], the BDD diagnosis can be obtained corresponding to ICD-11 and DSM-5 by evaluating the respective relevant criteria. The interview guideline assesses the core criteria preoccupation (item 1), self-consciousness and ideas of reference (item 2), repetitive behaviours and mental acts (item 3), avoidance (item 4) and impairment (item 5). Additional items for the insight (item 8) and muscle dysmorphia (item 7) specifiers, and eating disorder exclusion (item 6) are provided. Interview questions are supplemented by guidelines for the assessment of each criterion. Qualitative information is recorded about the body parts, the performed behaviours, and the impaired areas of life. For the ICD-11 diagnosis, the questions regarding preoccupation (Item 1), self-consciousness (Item 2) and suffering or impairment (Item 5) have to be answered positively, and either repetitive (mental) behaviours (Item 3) or avoidance (Item 4) are indicated. For the DSM-5 diagnosis, items 1, 3 and 5 have to be affirmed. For both, the exclusion of an eating disorder (Item 6) has to be considered.\u003c/p\u003e \u003cp\u003eDysmorphic Concern Questionnaire (DCQ).\u003c/p\u003e \u003cp\u003eWe used the German version [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] of the Dysmorphic Concern Questionnaire (DCQ) [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In the DCQ, participants rate dysmorphic worries on a 7-item scale with 0 = \u0026lsquo;not at all\u0026rsquo;, 1 = \u0026lsquo;like most other people\u0026rsquo;, 2 = \u0026lsquo;more than other people\u0026rsquo; and 3 = \u0026lsquo;much more than other people\u0026rsquo;. The aggregated score ranges from 0 to 21 with higher scores representing more pronounced dysmorphic worries. A cutoff value of 14 achieved an 84.6% accuracy in classifying BDD patients [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. A solid body of research indicates that the DCQ is a valid and reliable screening instrument [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan additionalcitationids=\"CR45\" citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. A recent study confirmed a good internal consistency of \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\alpha\\)\u003c/span\u003e\u003c/span\u003e = .81 and good convergent validity for a representative German sample [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBrief Symptom Inventory.\u003c/p\u003e \u003cp\u003eGeneral psychopathological distress was examined using a German version [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e] of the 18-item short form of the Brief Symptom Inventory (BSI-18) [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. The short version encompasses the three symptom areas \u003cem\u003eAnxiety\u003c/em\u003e, \u003cem\u003eDepression\u003c/em\u003e, and \u003cem\u003eSomatization\u003c/em\u003e, each represented by six items that are rated on a scale from 0 (\u0026ldquo;not at all\u0026rdquo;) to 4 (\u0026ldquo;very much\u0026rdquo;). Sum scores (ranging from 0 to 24) can be calculated for each syndrome. Taken together, the three syndromes constitute the Global Severity Index (GSI, range 0\u0026ndash;72) as a measure of general psychological distress. A representative German sample showed good internal consistency for each of the syndromes and very good internal consistency for the GSI, as well as favourable estimates of convergent validity [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. In the Iranian sample, the 53-item version of the BSI [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e] was used, for which psychometric quality is empirically supported [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. However, in order to enable a comparison with the German sample, only the corresponding items of the BSI-18 were evaluated for the Iranian sample.\u003c/p\u003e \u003cp\u003eBeck Depression Inventory.\u003c/p\u003e \u003cp\u003eThe German version of the BDI-Fast Screening (BDI-FS) [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e], a short form of the BDI-II [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e], was applied to measure depressive symptoms. For each item, one out of four statements is selected, resulting in a rating between 0 and 3. The total score ranges from 0 to 21, with higher values indicating more severe depressive symptoms. In a representative German sample, the one-factor structure and good internal consistency (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\alpha\\)\u003c/span\u003e\u003c/span\u003e = .84) along with good convergent and satisfying discriminant validity could be supported [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. For the Iranian sample, the BDI-V [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e] was translated into Farsi. The BDI-V is a simplified version of the BDI that applies a standard Likert scale (0\u0026ndash;5) to 20 items (sum score ranging from 0 to 100). This scale showed a good psychometric quality in a German sample [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSocial Phobia Inventory.\u003c/p\u003e \u003cp\u003eSymptoms of social anxiety disorder (SAD) were assessed with the Social Phobia Inventory (SPIN) [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e] in the German [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e] and Iranian versions [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. In the 17-item self-report screening instrument, participants rate social anxiety, avoidance and physiological aspects of social anxiety on a Likert scale between 0 and 4 (total score ranging from 0 to 68). In the German version of the SPIN, a very high internal consistency, good retest reliability, good validity and change sensitivity were shown [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. For the Iranian version, internal consistencies of \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\alpha\\)\u003c/span\u003e\u003c/span\u003e = .66 in a clinical and \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\alpha\\)\u003c/span\u003e\u003c/span\u003e = .89 in a non-clinical sample were found [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eReliability of the BDD-S was assessed by estimating the internal consistency with McDonald\u0026rsquo;s \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\omega\\)\u003c/span\u003e\u003c/span\u003e. To determine construct validity, correlations with another BDD measure and related constructs were calculated. We expected correlations\u0026thinsp;\u0026gt;\u0026thinsp;.70 for convergent measures, and lower values for divergent measures. We performed a ROC analysis on the German sample (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;486), using the DCQ score categorization based on the cutoff value of \u0026gt;\u0026thinsp;=\u0026thinsp;14 provided by Stangier et al. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. A first cutoff value was determined based on maximizing the sum of sensitivity and specificity. An alternative, more sensitive cutoff value was calculated by maximization of the sensitivity. From the BDD-CI, we estimated the prevalence in the German sample. Given that the interview was not conducted in the total sample due to limited resources, the prevalence could only be estimated indirectly. We first preselected eligible participants from the total German sample with a very liberal criterion to exclude people who did not confirm any relevant item. For these \u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;105 people, we assumed that the BDD diagnosis was not fulfilled. Among the \u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;381 eligible participants, 40 interviews were ultimately conducted. For the 341 people who were eligible, but not interviewed for various reasons (accessibility, no consent to interview), we assumed that the prevalence was comparable to that of the sample that was interviewed. In this way, we estimated a prevalence value for the entire German sample.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eDescriptive Statistics, Reliability and Item Analysis\u003c/p\u003e \u003cp\u003eThe means, standard deviations and McDonald\u0026rsquo;s \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\omega\\)\u003c/span\u003e\u003c/span\u003e values for the measured scales are given in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Internal consistency for the BDD-S was high. All items had a discriminatory power of 0.69 or higher, except item 15, which was still within the acceptable range (discrimination 0.31).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive data of all measured constructs\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eComplete Sample\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eGerman Sample\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eIranian Sample\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\omega\\)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBDD Screening\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e15.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e8.25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBSI-GSI (18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e19.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e14.30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSPIN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e11.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e10.84\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDCQ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBDI-FS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBDI-V\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e28.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e20.27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNote.\u003c/em\u003e Complete sample: \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;650, German sample: \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;486, Iranian sample: \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;164. McDonald \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\omega\\)\u003c/span\u003e\u003c/span\u003e is calculated for the complete sample where possible, or for the respective subsample that completed each measure.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eValidity\u003c/p\u003e \u003cp\u003eAs expected, we found high correlations (\u0026gt;\u0026thinsp;.70) with BDD symptom severity assessed by the DCQ and medium to large correlations with depression, general psychopathology and SAD symptoms for the German sample. In the Iranian sample, however, correlations of the BDD-S with the BDI, BSI and SPIN were considerably lower (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCorrelations of the BDD Screening with other measured constructs\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eComplete Sample\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eGerman Sample\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eIran Sample\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eExpected high correlation\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDCQ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eExpected medium correlation\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBDI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBSI-GSI (18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.024\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSPIN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNote.\u003c/em\u003e DCQ: Dysmorphic Concerns Questionnaire, BDI: Beck Depression Inventory, BSI-GSI: Brief Symptom Inventory Global Severity Index, 18-item version, SPIN: Social Phobia Inventory. \u003c/p\u003e \u003cp\u003eIn the German sample, the BDI-FS was used. In the Iranian sample, the BDI-V was used.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eCutoff Value\u003c/p\u003e \u003cp\u003eThe cutoff based on maximizing the sum of sensitivity and specificity was 19. This cutoff value reached a sensitivity of 0.92 and a specificity of 0.87. The area under the curve was 0.94. N\u0026thinsp;=\u0026thinsp;110 (22.63%) of the German sample and N\u0026thinsp;=\u0026thinsp;41 (25.00%) of the Iranian sample reached this value.\u003c/p\u003e \u003cp\u003eAn alternative cutoff point that maximizes sensitivity was 14. This cutoff value reached a sensitivity of 1.00 and a specificity of 0.64. The area under the curve was 0.94. This cutoff value was reached by N\u0026thinsp;=\u0026thinsp;199 (40.95%) of the German sample and N\u0026thinsp;=\u0026thinsp;70 (42.68%) of the Iranian sample.\u003c/p\u003e \u003cp\u003ePrevalence\u003c/p\u003e \u003cp\u003eBased on the ICD-11 criteria, four people (10.00%) fulfilled the diagnosis of BDD. Using the DSM-5 criteria, instead, five participants (12.50%) from the assessed sample fulfilled the diagnostic criteria for BDD. Among the diagnosed participants, one showed good to fair insight (two for DSM-5), and for three participants, insight was rated poor. Based on the ICD-11 criteria we estimated a prevalence of 2.76% for the whole sample. The \u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;105 participants who did not fulfil our interview eligibility criteria showed a mean BDD-S value of \u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4.33. The mean score of the interviewed patients was \u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;14.85 (\u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;7.80), which was not significantly different to that of the eligible patients who were not interviewed (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;15.05, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;7.24, \u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.15, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.878).\u003c/p\u003e \u003cp\u003eCultural Comparison\u003c/p\u003e \u003cp\u003eThe BDD-S total score of the German (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;12.72, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;7.96) and the Iranian sample (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;15.88, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;8.25) differed significantly (\u003cem\u003et\u003c/em\u003e = -3.92, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;.001) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eConsidering that the Iranian sample included only female participants, we also examined gender differences for the BDD-S score. In the German sample, the difference between female (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;13.49, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;7.95) and male participants \u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;10.09 \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;7.30) was significant (\u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4.26, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;.001). Comparing only female participants from the German and Iranian samples, the difference in BDD-S scores remained significant, however (\u003cem\u003et\u003c/em\u003e = -2.88, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.004).\u003c/p\u003e \u003cp\u003eThe BSI value was greater in the Iranian sample (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;19.91, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;14.30) than in the German sample (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;12.64, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;11.67 \u003cem\u003et\u003c/em\u003e = -5.67, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;.001). However, SAD symptoms were significantly greater in the German sample (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;15.65, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;13.41) than in the Iranian sample (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;11.28, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;10.84, \u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4.04, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we presented a new screening questionnaire (BDD-S) and a structured clinical interview guide (BDD-CI) for body dysmorphic disorder that incorporate the current diagnostic criteria from both the DSM-5 and the ICD-11. Content validity, as secured by up-to-date criteria, is crucial as the absence of important components or a diverging construct focus can lead to both under- and overrecognition. If BDD is not recognized, or misdiagnosed e.g. as mood disorder, the resulting inappropriate treatment, or lack thereof, leads to persisting psychopathology. Underrecognition also poses the risk of performing cosmetic surgery which is usually ineffective at reducing distress for BDD patients [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e]. Mitigating the underrecognition of BDD in the German psychiatric and medical care landscape will help to ensure that patients receive appropriate treatment according to relevant clinical guidelines. Screenings that lack recently added criteria (e.g. repetitive behaviours or avoidance) might instead cause overrecognition, causing a waste of resources, as performing diagnostic procedures is time-consuming. In a large representative German sample, the addition of the criterion of ritualistic behaviours did not lead to a difference in caseness determined by a clinical interview [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, this would likely be different in self-report questionnaires. Appearance-related concerns are common in the population [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e], and it is difficult for affected persons to assess whether their preoccupation with a flaw is clinically significant. Therefore, in self-report questionnaires, the inclusion of the more objective behaviour criterion is much more important for specificity. A lack of content validity can also cause difficulties in distinguishing common differential diagnoses, such as eating disorders. Accordingly, by providing a screening instrument with good content validity, the present investigation is an important contribution to the appropriate care of this patient population. Despite its relative prevalence in psychiatric and cosmetic surgery settings [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], medical staff and surgeons often lack knowledge about BDD [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. As patients usually do not report appearance-related concerns spontaneously out of shame or lack of insight [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], it is important to screen for BDD in routine assessments. Due to its quick and easy application, the BDD-S is a practical and useful tool intended to screen for BDD in all psychiatric, psychotherapeutic and medical settings. With the query of the relevant body parts and the existing control behaviours, individual qualitative information for therapy planning is also recorded here in a very economical way. The total BDD-S score can be interpreted as a dimensional estimate of symptom severity and can be used for monitoring therapy success. When an elevated BDD-S score indicates the need for further diagnostics, the BDD-CI can be used as a follow-up by trained professionals to obtain the BDD diagnosis. It enables the determination of a valid diagnosis according to ICD-11 and DSM-5, by evaluating the appropriate criteria. The screening questionnaire was translated into Farsi, as the dissemination of adequate and validated measurement instruments is lacking, and the rapidly increasing field of research can benefit from this.\u003c/p\u003e \u003cp\u003ePsychometric quality of the BDD-S\u003c/p\u003e \u003cp\u003eWe found an excellent internal consistency of the BDD-S. Content validity is assured because the items were derived from the diagnostic criteria in the ICD-11 and the DSM-5. As shown by the high correlation with the DCQ, the construct validity of the BDD-S is good. The moderate to high correlations with other psychopathological constructs reflect the expected relationship to comorbid disorders and psychopathological burden [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e]. We suggested two different cutoff values that prioritize different criteria. The choice of the appropriate cutoff value may vary depending on the setting. The recommended value for general screening in a low-risk population or routine mental health care is 19. This value balances a high sensitivity of 0.92 and specificity 0.87, to combine a good recognition with time efficiency. As cosmetic surgery-seeking patients show a high prevalence of BDD [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], the more sensitive cutoff value (14) might be appropriate here, as well as in specific clinical settings and other high-risk populations.\u003c/p\u003e \u003cp\u003ePrevalence Estimate\u003c/p\u003e \u003cp\u003eThe prevalence in the German sample was estimated to be 2.76%, applying the ICD-11 criteria. This value is in line with previous findings, which estimated the prevalence in German adults between 1.7% and 2.9% [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], and somewhat higher than the weighted estimate (1.9%) from a cross-national study [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, it is important to note here that our prevalence estimate is based only on a subsample (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;40), from which the value was extrapolated to the entire sample. Possible biases in the selection of samples and thereby limited generalizability cause uncertainty and the estimate should therefore be interpreted with caution. If the criteria according to DSM-5 are evaluated, a slightly higher number of cases is obtained. The ICD-11 criteria allow for avoidance to be the only behavioural consequence of the appearance preoccupation but require self-consciousness or ideas of reference to be present. This might explain the difference in caseness in our sample.\u003c/p\u003e \u003cp\u003eCulture Comparison\u003c/p\u003e \u003cp\u003eWe found a higher total BDD-S score for the Iranian sample. This is consistent with the fact that comparatively high prevalences were found in cosmetic surgery settings [\u003cspan additionalcitationids=\"CR37 CR38 CR39 CR40 CR41\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e] and student samples [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e] in Iran, compared to global studies from the same subpopulations [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, there are no direct comparison studies between Germany and Iran that can be used as a reference. Notably, the BSI values are significantly greater in the Iranian sample, as well, while SAD symptom severity is greater in the German sample. Due to the different BDI questionnaire versions used, it is not possible to compare the depression values of the two samples, which is a limitation of our study. Overall, our findings support earlier research showing that BDD might be more prevalent in the Iranian population, in connection with high psychopathological distress (BSI). However, selection effects may be involved and must be taken into account as possible alternative explanation for the higher BDD-S values.\u003c/p\u003e \u003cp\u003eStrength and Limitations, Future Studies\u003c/p\u003e \u003cp\u003eA strength of this study was the size of the complete sample (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;650). Since the smaller Iranian sample consisted only of women, results can of course only be generalized to the female population. As only part of the German sample (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;40) completed the interview, the prevalence stated is only a preliminary estimate and must be checked on further samples. The study was conducted using convenience samples from the general population, therefore an important limitation is the lack of clinical data. The next step is therefore the validation of the screening scale and the clinical interview in patient populations. Future studies with clinical and healthy populations should reassess the proposed cutoff values, and provide more data to evaluate the construct validity.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eTo summarize, in this article we preliminarily validated a new screening instrument and clinical interview for BDD. These are the first measurement instruments to reflect the currently valid criteria from both ICD-11 and DSM-5. It is of great value to provide questionnaires that assess BDD according to the current criteria, as many older screening questionnaires have a different focus in terms of content, which can lead to over- or underrecognition. The proposed instruments therefore contribute to the correct identification of patients with BDD and thus to improved psychiatric and medical care.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; AUC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Area Under the Curve\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; BDD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Body Dysmorphic Disorder\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; BDD-CI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Clinical Interview for Body Dysmorphic Disorder\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; BDD-S\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Body Dysmorphic Disorder Screening Scale\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; BDD5-S\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Body Dysmorphic Disorder Screener for DSM-5\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; BDI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Becks Depression Inventory\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; BSI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Brief Symptom Inventory\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; COPS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Cosmetic Procedure Screening Questionnaire\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; DCQ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Dysmorphic Concerns Questionnaire\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; DSM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Diagnostic and Statistical Manual of Mental Disorders\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; GSI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Global Severity Index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; ICD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; International Statistical Classification of Diseases and Related Health Problems\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; OCRD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Obsessive-Compulsive and Related Disorders\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; SAD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Social Anxiety Disorder\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; SCID-5-RV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Structured Clinical Interview for DSM-5, Research Version\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; SPIN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Social Phobia Inventory\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eThe ethics committee of the Department of Psychology and Sports Science at the Goethe University Frankfurt approved the procedures (Reference number 2021-04). Participants provided informed consent to all study procedures.\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eAs the data sets analysed in the current study are clinical data they are not made publicly available.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eNo funding was used for this project outside of university funds.\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026rsquo; contributions\u003c/h2\u003e\n\u003cp\u003eJS was involved in the conceptualization of the study design, administered the project, collected data for the German sample, curated, analyzed and interpreted the data, and created the first draft of the manuscript. ME collected data for the German sample, contributed to the formal analysis and with the first draft of the manuscript. FT collected data for the Iranian sample and reviewed the manuscript. VR was involved in the conceptualization of the study design, and administration of the project, provided supervision and reviewed and edited the manuscript. US was involved in the conceptualization of the study design and administration of the project, provided supervision and reviewed and edited the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eWe would like to thank Anna Chlup and Sophia Jacqueline Pieronczyk for their support in conducting the interviews.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAPA. Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition. 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An empirically derived recommendation for the classification of body dysmorphic disorder: Findings from structural equation modeling. PLoS ONE. 2020;15:e0233153. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1371/journal.pone.0233153\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0233153\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Body Dysmorphic Disorder, Diagnostic Interview, Screening Scale, ICD-11, DSM-5, Culture Comparison","lastPublishedDoi":"10.21203/rs.3.rs-3879165/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3879165/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eBody dysmorphic disorder (BDD) is an impairing psychological disorder with a high prevalence in clinical and cosmetic surgery settings. In the new ICD-11, BDD is grouped with the obsessive-compulsive spectrum disorders and the diagnostic criteria are updated, largely corresponding with the DSM-5. Available diagnostic interviews and screening scales for BDD are not based on these current criteria. In this paper, a newly developed screening questionnaire (BDD-S) and structured clinical interview (BDD-CI) according to the ICD-11 and DSM-5 criteria were preliminarily validated.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe BDD-S and the BDD-CI cover all core BDD symptoms. Open-ended questions allow for the addition of qualitative information on affected body parts and behavioural and mental aspects. We determined the internal consistency and construct validity of the BDD-S and suggested a cutoff value. We assessed a subsample with the BDD-CI and estimated a prevalence. The BDD-S was translated into Farsi and applied to an Iranian sample. BDD-S scores, social anxiety symptoms, and general psychopathological impairment were compared between a German and an Iranian sample.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eInternal consistency of the BDD-S was excellent (ω\u0026thinsp;=\u0026thinsp;.92). A high correlation with the body dysmorphic concerns and moderate correlations with measures of other mental disorders supported good construct validity. We determined a cutoff value of 19 for balanced sensitivity and specificity (sensitivity\u0026thinsp;=\u0026thinsp;0.92, specificity\u0026thinsp;=\u0026thinsp;0.87, AUC\u0026thinsp;=\u0026thinsp;.94). We estimated a prevalence of 2.76% for the German sample. The cultural comparison showed that the BDD-S score was higher in the Iranian sample.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eWith the BDD-S, we developed an economic and versatile screening instrument based on current diagnostic criteria, to be followed up with the BDD-CI when applicable, to obtain a clinical diagnosis. In the next step, the measures must be validated in larger clinical samples.\u003c/p\u003e","manuscriptTitle":"Validation of a German Body Dysmorphic Disorder Screening Scale and Clinical Interview according to ICD-11 and DSM-5 in the General Population","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-24 19:46:25","doi":"10.21203/rs.3.rs-3879165/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"53fd2760-71ee-4b60-8a23-ed05d29eb978","owner":[],"postedDate":"January 24th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-07-08T06:45:20+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-24 19:46:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3879165","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3879165","identity":"rs-3879165","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}